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May 3, 2022 Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 e926 CLINICAL STATEMENTS AND GUIDELINES A recent pilot RCT N=27) showed that providing patients with 1.5 g/d sodium meals can reduce urinary sodium and improve QOL but not improve clinical outcomes.3 Another recent pilot RCT (N=38) of 1.5 versus 2.3 g/d sodium resulted in sodium intake and improvement in BNP levels and QOL in the 1.5 g/d sodium intake arm5; the full trial is due to be completed in 2022. A third pilot RCT (N=66) of home-delivered 1.5 g/d meals showed favorable but nonsignificant trends toward improvement in clinical status and readmission rates.6 Moreover, results from RCTs have shown that reducing dietary sodium is difficult to achieve in patients with HF, even with prepared meals3 or home visits.26 7.1.3 Management of Stage C HF: Activity, Exercise Prescription, and Cardiac Rehabilitation Recommendations for Management of Stage C HF: Activity, Exercise Prescription, and Cardiac Rehabilitation Referenced studies that support the recommendations are summarized in the Online Data Supplements. COR LOE Recommendations 1 A 1. For patients with HF who are able to participate, exercise training (or regular physical activity) is recommended to improve functional status, exercise performance, and QOL.1–9 2a B-NR 2. In patients with HF, a cardiac rehabilitation program can be useful to improve functional capacity, exercise tolerance, and health-related QOL.1,2,5,6,8 Table 11. Potential Barriers to Effective HF Self-Care and Example Interventions Potential Barrier Example Screening Tools Example Interventions Medical Barriers Cognitive impairment48–50 Mini-Cog Mini-Mental State Examination (MMSE) Montreal Cognitive Assessment (MoCA) Home health aide Home meal deliveries Adult day care Geriatric psychiatry referral Memory care support groups Depression51,52 Hamilton Depression Rating Scale (HAM-D) Beck Depression Inventory-II (BDI-II) Patient Health Questionnaire-9 (PHQ-9) Psychotherapy Selective serotonin reuptake inhibitors Nurse-led support Substance use disorders53 Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Referral to social work services and community support partners Referral for addiction psychiatry consultation Frailty54 Fried frailty phenotype Cardiac rehabilitation Registered dietitian nutritionist evaluation for malnutrition Social Barriers Financial burden of HF treatments55 COmprehensive Score for financial Toxicity–Functional Assessment of Chronic Illness Therapy (COST-FACIT) PharmD referral to review prescription assistance eligibilities Food insecurity56,57 Hunger Vital Sign, 2 items US Household Food Security Survey Module, 6 items Determine eligibility for the Supplemental Nutrition Assistance Program (SNAP) Connect patients with community partners such as food pantries/ food banks Home meal deliveries Registered dietitian nutritionist evaluation for potential malnutrition Homelessness or housing insecurity58–60 Homelessness Screening Clinical Reminder (HSCR) Referral to local housing services Connect patients with community housing partners Intimate partner violence or elder abuse61,62 Humiliation, Afraid, Rape, Kick (HARK) questionnaire Partner Violence Screen (PVS) Woman Abuse Screening Tool (WAST) Referral to social work services and community support partners Limited English proficiency or other language barriers63 Routinely inquire in which language the patient is most comfortable conversing Access to interpreter services covering a wide range of languages, ideally in person or, alternatively, via video platform Printed educational materials in a range of appropriate languages Low health literacy64 Short Assessment of Health Literacy (SAHL) Rapid Estimate of Adult Literacy in Medicine–Short Form (REALM-SF) Brief Health Literacy Screen (BHLS), 3 items Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit Written education tools provided at sixth grade reading level or below Graphic educational documents Social isolation or low social support65 Patient-Reported Outcomes Measurement Information System (PROMIS) Social Isolation Short Form Determine eligibility for home care services Support group referral Transport limitations No validated tools currently available. Referral to social work services Determine eligibility for insurance or state-based transportation, or reduced-cost public transportation Maximize opportunities for telehealth visits and remote monitoring HF indicates heart failure. Downloaded from http://ahajournals.org by on October 7, 2026